Preparing for the Next Pandemic
The next pandemic is coming. Smart planning and investment in supplies now will save money and lives.
THE MOONSHOT: As recently as late 2019, only public health experts and a few prescient journalists, filmmakers, philanthropists, and politicians were thinking seriously about the threat of a pandemic. Now, we are all painfully aware of what chaos a novel, highly infectious pathogen can inflict. One of the best ways countries can limit illness and death is to have full stockpiles of protective equipment, drugs, and vaccines ready to deploy. What supplies are needed depends to some extent on the disease being faced, but less than one might think. The pathogens likely to cause the next pandemic share common features, and these similarities allow countries to plan ahead. A sturdy commitment to maintain national stockpiles could lessen the severity of future pandemics, prevent the overrun of public health systems, and avert costly lockdowns.
THE PHILANTHROPY OPPORTUNITY: Given sufficient political will and focus, rich nations can afford to build public-health stockpiles, but poorer countries often cannot. When the coronavirus hit, 10 African countries had no ventilators, for example. Philanthropists are now among those striving to provide needed equipment to health agencies and hospitals around the world. In the future, both public and private donors can help ensure that every country has the equipment, drugs, vaccines, and technological infrastructure it needs to confront emerging pathogens, limit their spread, and save lives.
Much is still unknown about the post-Covid-19 future. But one prediction is almost certain to be correct: The world will be visited by more pandemics. Plagues have been with humanity since the beginning of recorded history, and likely far earlier. In recent decades, the conditions for pathogens to spill over from animals to humans, and for humans to rapidly move those pathogens around the world, have increased dramatically.
“With rapidly changing ecology, urbanization, climate change, increased travel and fragile public health systems, epidemics will become more frequent, more complex and harder to prevent and contain,” wrote an international group of authors in Nature in late 2019, just as the novel coronavirus, dubbed SARS-CoV-2, was infecting its first victims.
Despite many years’ worth of warnings from philanthropist Bill Gates, public health experts, and public officials — including the previous two U.S. presidents — governments around the world have lagged in preparing for pandemics. The United States depleted its emergency supply of masks and personal protective equipment previously stowed in the Strategic National Stockpile during the 2009 H1N1 influenza pandemic and failed to adequately resupply, for example. A plan in that pandemic’s aftermath to contract with private companies for thousands of ventilators fell apart, leaving the nation’s health system under-resourced and exposed. And manufacturers of critical drugs became dependent on complex and opaque supply chains that are now crumbling. These weaknesses went mostly unnoticed until exposed by the Covid-19 crisis.
The next pandemic need not deliver such a shock. It is possible to predict what classes of pathogens are most likely to launch a future pandemic — and what supplies will be needed.
Several organizations have assembled prioritized pathogenic disease threat lists. The World Health Organization’s list includes the following:
- Covid-19
- Crimean-Congo hemorrhagic fever
- Ebola virus disease and Marburg virus disease
- Lassa fever
- Middle East respiratory syndrome coronavirus (MERS-CoV) and Severe Acute respiratory Syndrome (SARS)
- Nipah and henipaviral diseases
- Rift Valley fever
- Zika
- “Disease X,” which represents an as yet unknown infectious disease that is both highly contagious and lethal
For its part, the Coalition for Epidemic Preparedness Innovations (CEPI), prioritizes these diseases:
- MERS
- Lassa
- Nipah
- Rift Valley Fever
- Chikungunya
- Disease X
Gavi, a philanthropic alliance to make vaccines available globally, has compiled a similar list.
Although all of the pathogens that cause these diseases are capable of spreading into devastating and deadly outbreaks, only a subset pose serious threats of setting off a global pandemic. To do that, pathogens must have a way to get from human body to human body efficiently and avoid detection long enough to hitch rides both locally and globally inside their human hosts. They also must be invincible to antibiotics, which, for now, can handle bacterial outbreaks. For the most part, this combination of factors is what makes respiratory viruses such standouts, says Jennifer Nuzzo, an epidemiologist with the Center for Healthy Security at Johns Hopkins University in Baltimore, MD.
Before SARS-Cov-2, many experts believed the next pandemic would be caused by an influenza virus. Unlike coronaviruses, flu viruses circulate widely every year. And they mutate constantly, finding new ways to exploit human cells for reproduction and transmission. In the past 20 years, H5N1 (bird flu) and H1N1 (swine flu) created scares, but in both cases, humanity got lucky; the former was not very transmissible and the latter not very deadly. There’s no guarantee future flu strains will be so kind. The last major global pandemic before Covid-19, the so-called Spanish flu of 1918–1919, killed more than 50 million people and sickened up to 40% of the global population.
“If you took a poll of those of us who work on pandemic diseases any time in the last 10 years, and asked, ‘What do you predict will be next global pandemic that results in greater than 100,000 deaths?’ I’m pretty confident that the winner would have been influenza,” says Stephen Luby, professor of infectious disease at Stanford University in California. “We’ve seen it do it before, we know it can do it, and there continue to be new strains emerging all the time.”
Indeed, the specter of a new potential flu pandemic reared its head on June 29, when researchers reported a new strain of swine flu circulating among humans in China.
Other pathogens with pandemic potential include coronaviruses such as SARS, MERS, and the current SARS-Cov-2; Nipah and other henipaviruses, and so-called the so-called “Disease X” agent — an unknown pathogen that proves both deadly and highly contagious. (Covid-19 fits that description, but that doesn’t mean another Disease X can’t emerge. Virologists estimate that the planet may host more than a trillion viruses currently unknown to science.)
Given the persistent threat posed by highly infectious diseases, countries need to plan ahead to avoid another Covid-19-like disaster. Now is the time to start thinking about rebuilding public health stockpiles depleted by the current pandemic and building new ones in nations that have not traditionally maintained such stockpiles.
Once a highly transmissible, highly lethal virus makes the leap from animals to humans and starts spreading, a rapid, aggressive, and sustained response by public health and medical systems is the best way to minimize illness and death. As Covid-19 has shown, a poorly equipped — or a poorly managed — system will struggle, causing more people to become seriously ill and exacerbating shutdowns that cripple much of society.
Researchers have looked closely at what a robust response to a new, hyper-virulent flu would entail. In a study published in 2009, epidemiologists modelled what supplies would be needed to respond to a Spanish-flu-like pandemic in the United States, which could sicken a quarter of the population, or some 82 million people. (As of this writing, 3.53 million Americans, or 1.08% of the population, had been diagnosed with Covid-19, though the the director of the Centers for Disease Control and Prevention (CDC) has speculated that as many as 10 times more may have been infected.)
The 2009 recommendations map roughly onto what has proven lacking in the coronavirus response: personal protective equipment such as masks and respirators, drugs to treat patients, ventilators to supply oxygen to lungs of the severely ill, and swabs and reagents for tests. But the numbers were sobering. For just one network within the Veterans Administration health system that cares for around 500,000 people, the team found the following needs (and this is just a subset of all required equipment):
Gloves — 6,130,392
Gowns — 3,065,196
N95 disposable respirators — 210,000
Goggles — 10,000
Reusable respirators — 10,000
Reusable respirator filter cartridges — 30,000
Disposable masks (for patients) — 75,000
Disposable ventilators — 600
Ventilator supplies — 1032
The researchers calculated a total cost of around $11 million for the needed equipment, which the authors noted was far more money than what was available. If scaled up to a national population of 328.2 million, the cost becomes a projected $7.2 billion — just for one pandemic. Pre-Covid, spending such an amount on pandemic preparedness might have seemed wildly unrealistic; now it looks like a steal. Fortunately, many of the supplies needed are generic to any respiratory virus, because they are designed to prevent droplets or aerosols from being transmitted from an infected person to others. That makes stockpiling simpler and more politically palatable; stockpiles of basic personal protective equipment protect against not just one respiratory virus but all respiratory viruses. Drugs and vaccines, by contrast, tend to be specific to a type of virus.
The U.S. Strategic National Stockpile comprises at least six enormous warehouses spread around the country, stockpiling some 1000 items. Some states operate their own stockpiles in addition, and New York City is creating one in the wake of the experience of being overwhelmed by the coronavirus and unable to meet its needs through the federal stockpile.
A vexing question, however, is whether every country needs its own similar stockpile. Some small island nations, for example, have tried to develop agreements with larger, wealthier countries for pandemic responses such as laboratory testing, which can require expensive equipment such as machines to carry out DNA-amplifying polymerase chain reactions. When a pathogen hits every country simultaneously, however, it can become politically challenging for one country, even a wealthy one, to devote resources to another, says Nuzzo. In a report published last fall, she and colleagues ended up recommending that even poorer, smaller nations should probably develop their own stockpiles and testing labs, to the extent possible.
“From an ideal standpoint, we would have a global stockpile that’s allocated where needed,” Nuzzo said. “But the politics of these events make that very difficult. Countries that don’t have their own resources have to understand that that limits them.”
One type of supply specific to a flu pandemic is the existence of effective, tested antiviral drugs such as Tamiflu and Relenza that can make infections less severe. In 2011, a group of authors estimated the volumes of antivirals that would be needed for responding to a flu pandemic. They found that countries should stockpile enough antivirals to treat at least 15% of their population — 49.2 million people in the United States — and cautioned that because some drugs will inevitably be misallocated, 25% may be a safer number. The authors noted that such a stockpile is unrealistic for many poorer countries and called on the international donor community to help those nations gain access to supplies.
The most potent weapon against a virus is a vaccine that confers immunity. Because vaccines are specific to a pathogen, however, they cannot be produced until that pathogen has revealed itself and started causing havoc.
Covid-19 has set in motion the largest and most rapid vaccine development effort the world has ever seen. As of this writing, at least 140 potential vaccines are being investigated, with at least 16 already in clinical trials. But experts caution that a safe, effective vaccine that can be deployed on a global scale is likely still one to multiple years away.
Once a vaccine becomes available, it will need to be produced in massive quantities: Virtually the entire human population will be potential recipients. And assuming that, as with most vaccines, one dose does not confer lifelong immunity, boosters may be needed. For the foreseeable future, Covid-19 vaccine stockpiles and manufacturing capability will need to be integrated into every country’s public-health infrastructure. CEPI estimates that the effort to test and manufacture a global supply of the vaccine will cost more than $3 billion; the Gates Foundation has already begun funding the effort.
For other pathogens with pandemic potential, vaccine research is ongoing. CEPI, for example, is developing four vaccine candidates against Nipah, a respiratory and encephalitic virus that causes brain swelling, vomiting, dizziness, coma, and other symptoms, and kills up to 75% of people it infects — a truly macabre death rate that inspired director Steven Soderbergh to base his 2011 film Pandemic on it. Nipah is relatively easy to target with a vaccine, says Stanford’s Luby. That’s good, because there is no effective therapy against Nipah, and it is so deadly that, should it mutate to become efficiently transmitted, Luby says, “it would be the deadliest epidemic the world has ever faced.”
In March, CEPI announced that one of its Nipah vaccine candidates had entered clinical trials. Once a Nipah vaccine is ready, it will need to be manufactured en masse, distributed to different countries, and replenished at regular intervals. While that will take time, Luby feels confident “we’ll have a stockpile sitting there within 10 years.” A certain number of doses will need to be stored in countries such as Bangladesh and Malaysia that have proven vulnerable to Nipah outbreaks, and countries will need “surge capacity” to produce many more doses quickly. A CEPI spokesperson says the group plans to manufacture 100,000 does for an “investigational stockpile,” to be distributed among countries in Asia, Oceania, and Africa that host the fruit bats that are the disease reservoir. Ultimately, a surge capacity in the tens of millions will need to be manufactured, most likely spearheaded by national governments and philanthropic organizations like Gavi.
All this will need to be done, of course, while nations recover from the current pandemic, which means, among other things, rebuilding economies and restocking arsenals against future flu and coronavirus pandemics.
“It’s been proven that every dollar invested in prevention for disease surveillance has a 10-fold value [compared to] what it would cost if there were an outbreak.” — Mark Smolinski, Ending Pandemics
For better-studied pathogens, “platform” technology allowing the rapid manufacture of vaccine is the key. That is what allows countries to deploy a semi-effective annual flu vaccine, despite the fact that new flu strains appear every year. But even for relatively mature vaccine platforms, supply chains could quickly become stressed in a pandemic situation. Christian Lindmeier, a public affairs specialist with the World Health Organization in Geneva, writes: “For a future influenza pandemic there are a wide range of supplies that may be in short supply.”
For example, Lindmeier notes, many influenza vaccine production lines rely on pharmaceutical-grade fertilized hens’ eggs. Eggs are perishable and cannot be stockpiled, so flocks that provide these eggs would need to be protected from being infected by a pandemic influenza strain. (Some countries have transitioned to tissue-culture-based production methods to get around these vulnerabilities.)
Mark Smolinski, president of the San Fransisco, California-based nonprofit Ending Pandemics, agrees that medical supplies, drugs, and vaccines are crucial to stopping pandemics today. (Read another Moonshot Catalog article about ending pandemics altogether.) But in the future, he would like to see all countries have the capacity to nip potential pandemics in the bud. That means every country will need to vastly ramp up surveillance systems to help people report infections to public health agencies, which can then act swiftly enough to quench outbreaks before they rage into pandemic wildfires.
A country not often held up as an international model is showing how this might be done. In Cambodia, Smolinski and colleagues convened what he calls an “EpiHack” that led to the development of a toll-free national hotline for crowdsourcing disease outbreak reports from people who are not medical experts but are likely to be the first to notice a new zoonotic disease — that is, a disease that spills over from an animal host to humans. Before coronavirus hit, the hotline started receiving 600 calls a day, of which 20 to 30 needed to be investigated, says Smolinski. As of late April, when coronavirus spread was on the rise, the hotline was receiving at least 15,000 phone calls a day, and the government had hired 25 new operators.
As of this writing in July, Cambodia had only 166 reported Covid-19 cases and zero deaths. (Some commentators have questioned whether the country was testing adequately.)
“You can’t build that…during an emergency,” Smolinski says, but if such a surveillance infrastructure is already in place, “boy, it can be dialed up.”
Where is the need greatest?
Poor countries are, in general, the least prepared for a disease outbreak, but in situations like the West African Ebola epidemic of 2014–2016, they could at least count on aid from countries that were not directly hit. In a global pandemic that forces countries to focus on their own needs, the imperative for less affluent countries to be self-sufficient becomes even clearer.
As just one measure of the disparities faced in the developing world, The New York Times reported in April that 10 African countries started the coronavirus pandemic with no ventilators at all, and six other nations’ stockpiles of the vital technology numbered in the single digits. Philanthropists have pledged help; the Chinese billionaire Jack Ma and the Alibaba Foundation, for example, have reportedly supplied 300 ventilators, 500,000 Covid-19 testing kits, and millions of pieces of personal protective equipment to the Africa Centres for Disease Control in Addis Ababa, Ethiopia, to be distributed throughout the continent. But this is just the start of what is needed to protect the more than 1 billion people living in Sub-Saharan Africa, and some have argued for more appropriate technology that doesn’t rely on medical infrastructure often unavailable in poor or rural areas.
Pandemic preparedness is “where philanthropic dollars could make a really, really huge difference,” Smolinski says, noting that the leverage of value is enormous. “It’s been proven that every dollar invested in prevention for disease surveillance has a 10-fold value [compared to] what it would cost if there were an outbreak.”
Nuzzo agrees. “We’ve seen there’s more money for response than there is for preparedness,” she says. “It would be really helpful for needed resources to be brought to bear in advance of a situation…It will wind up saving money and lives.”
She sees roles for philanthropy both in directly supporting stockpiles and in supporting technical analyses to help smaller countries best allocate limited resources to prepare for future pandemics.
Says Nuzzo: “I really think that’s where the donor community steps in: to be able to say, ‘Listen, we need to figure out an approach that protects these individual countries, that works in these kinds of scenarios.””
While low-income countries may have the most acute needs, no nation was perfectly prepared for Covid-19, whose death toll as of this July posting was 586,000 and still rising. A moonshot-caliber project to prepare every country for the next pandemic would save immensely in the currency of both economics and human loss and misery.
Gabriel Popkin is a freelance writer based in Mount Rainier, Maryland.
